The Ins and Outs of HIPAA Transaction Compliance Published with permission of the American Medical Association (AMA) he healthcare industry has increasingly moved from paper and telephone communications toward electronic interactions for the exchange of information. Designed to eliminate idiosyncratic health plan electronic communication methods and to reduce administrative burdens and financial waste in the industry, HIPAA created standard electronic transactions for use in the exchange of information between providers and health plans. In this effort to streamline provider health plan communications, HIPAA standardized the following provider-related electronic THE JOURNAL OF THE HEALTHCARE BILLING AND MANAGEMENT ASSOCIATION 25 transactions: • Patient eligibility and benefit information requests • Referral certification and authorization (prior authorization) • Healthcare claims • Healthcare claim status and response • Electronic remittance advice • Electronic funds transfers The uniformity promoted by the standardized electronic transactions offers all industry stakeholders the opportunity for increased efficiency and fiscal savings. However, health plans must be compliant with the standard transaction requirements for these intended benefits to be achieved in the physician practice. General Rules While the regulation establishes specific rules associated with each of the standardized transactions listed above, HIPAA also created overarching health plan responsibilities that apply to all of the covered transactions. According to the regulation, health plans must comply with each of the following when conducting any standard transaction: • If a physician would like to conduct a transaction in the standard form, the health plan may not refuse to do so. • A health plan may not delay or reject a transaction on the basis that it is in the standard format. • A health plan may not reject a standard transaction on the basis that it contains data not needed or used by the health plan. • A health plan may not offer an incentive for a healthcare provider to conduct a standard transaction in a nonstandard format. • A health plan that uses a clearinghouse to process a standard transaction may not charge fees or costs above what it would cost to process the same transaction directly with the health plan. It should be noted that the regulation does not require physicians to use the standard transactions, only that the health plans support them if requested by the physician. However, health insurer contracts may require physicians to use the standard transactions. Specific Transaction Rules In addition to the general rules, health plans must adhere to each of the transaction-specific requirements recognized under HIPAA. In order to be compliant with the HIPAA regulations, health plans must conduct electronic transactions in accordance with the standards and operating rules for each of the covered transactions. Transaction standards are developed by the Accredited Standards Committee (ASC) X12, a standards development organization that focuses on standards development for electronic information exchanges. The Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) creates operating rules for the standard transactions. The operating rules specify additional requirements for the HIPAA electronic transactions that are not included in the ASC X12 standards. The ASC X12 standards and the CAQH CORE operating rules establish specific parameters and requisite details for conducting the individual transactions. For example, the standards and operating rules require health plans to provide deductible, co-pay, coinsurance, remaining deductible, and remaining co-insurance information when responding to a physician’s patient eligibility and benefit information request. T
Billing_MarApr15
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